Integrated Care Model for Screening and Multidisciplinary Collaboration of Community Patients with Atrial Fibrillation

doi:10.12114/j.issn.1007-9572.2020.00.189

Abstract

Abstract: With the aging of the population，atrial fibrillation（AF） has become a major public health problem in China and worldwide.AF is an important risk factor for stroke，cardiovascular disease and embolism，which seriously threatens patient's health and quality of life.Studies abroad have shown that a multidisciplinary，nurse-led，patient-centered integrated care model can help reduce the readmission rate，incidence of cardiovascular events，and all-cause mortality of AF patients，as well as improve their satisfaction and quality of life.At present，there are many problems in the AF management in China，and a standardized integrated care model has not yet been formed.Based on domestic and foreign AF management guidelines and related literature，this paper reviewed the process of integrated care model for AF，including its screening，comprehensive evaluation，management strategy development，health education，regular follow-up and referrals，and specific content of each process.The process of AF screening and integrated care model suitable for the community in China were formulated preliminarily in this paper，which could provide a reference for the establishment of a AF standardized management system in the community.

Key words: Atrial fibrillation, Screening, Community health services, Multidisciplinary cooperation, Integrated management

摘要： 随着人口老龄化的日趋严重，心房颤动（AF）已经成为我国乃至世界面临的重大公共健康问题。AF是引起脑卒中、心血管疾病、栓塞等疾病的重要危险因素，严重影响患者的健康水平和生活质量。国外研究表明，由多学科协作、以护士为主导、以患者为中心的综合管理模式，有助于降低AF患者的再入院率、心血管事件发生率及全因死亡率，提高患者满意度和生活质量。目前，我国AF管理存在诸多问题，尚未形成规范的综合管理模式。本文基于国内外AF管理指南和相关文献，梳理了AF综合管理模式的流程（包括筛查、综合评估、制定管理策略、健康教育、定期随访、转诊）及各流程的具体内容，初步制定出适合我国社区的AF筛查流程和综合管理过程，可以为构建社区AF规范化管理体系提供参考与依据。

关键词: 心房颤动, 筛查, 社区卫生服务, 多学科协作, 综合管理

LIU Yanli,MA Li. Integrated Care Model for Screening and Multidisciplinary Collaboration of Community Patients with Atrial Fibrillation　[J]. Chinese General Practice, 2020, 23(7): 774-778. DOI: 10.12114/j.issn.1007-9572.2020.00.189.
刘艳丽,马力. 社区心房颤动患者筛查及多学科协作的综合管理模式研究[J]. 中国全科医学, 2020, 23(7): 774-778. DOI: 10.12114/j.issn.1007-9572.2020.00.189.

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